Provider Demographics
NPI:1023063476
Name:ANDERSON, SU YUNG (PA)
Entity type:Individual
Prefix:
First Name:SU
Middle Name:YUNG
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:660 ELMWOOD DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1870 INDEPENDENCE SQ
Practice Address - Street 2:SUITE D
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-5155
Practice Address - Country:US
Practice Address - Phone:770-396-6190
Practice Address - Fax:770-396-5541
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002713367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS08417Medicare UPIN